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2012 POLMED BENEFITSPOINTS TO CONSIDER WHEN CHOOSING THE LOWER PLAN:
E It is important that family medical history is taken into account when choosing a plan.E Members may only be hospitalised in designated service provider (DSP) hospitals.E You will be liable for a co-payment of R8 000 if you are hospitalised in a non-DSP hospital.E The plan offers reasonable out-of-hospital limits.E It is intended for families who have little healthcare needs – generally healthy families.E It is also intended for members whose chronic conditions are under control.E It is not intended for members who seek medical assistance on a regular basis.E Certain benefits will not be funded while in hospital – refer to in-hospital benefits.E Changing to another plan can only happen once per year – before 31 December.Client Service Centre:Health Advice Line:
Tel: 0860 765 633 or 0860 POLMED
Tel: 0860 104 111
Fax: 0860 104 114
Fraud hotline:
Tel: 0800 200 564
Fax: 0861 888 110
Emergency Medical Assistance – Confidential HIV/AIDS line: Netcare 911:
Tel: 0860 104 112 Fax: 0861 113 136
Specialised dentistry pre-authorisation: E-mail address for submitting enquiries:
Tel: 0860 104 111 Fax: 0861 113 138
Chronic Medicine Management: POLMED website:
Tel: 0860 765 633 Fax: 0861 113 134
Hospital pre-authorisation: POLMED mobile website:
Tel: 0860 104 111 Fax: 0861 113 133
http://m.polmed.co.za(This service is available via your cell phone.)
Pre-authorisation is required for items funded from the chronic
All admissions to hospitals, day clinics and out-patient units
medication benefit. Pre-authorisation is based on evidence-
must be pre-authorised, otherwise a penalty of R1 000 will be
based medicine principles and the funding guidelines of
the Scheme. The member needs to re-apply at least one month prior to the expiry of the existing chronic medication
In the case of an emergency, the Scheme must be notified
within 48 hours or on the first working day after the admission.
The Scheme shall only consider claims for medicines obtained
Pre-authorisation will be managed under the auspices of
on the written prescription of a person legally entitled to
managed healthcare.
prescribe medicine and dispensed by such person or a registered pharmacist.
The appropriate facility has to be used to perform a procedure, based on clinical requirements and the expertise of the doctor
Flu vaccines are obtainable without a prescription.
doing the procedure.
Benefits for semi-private rooms are excluded unless they are
Specialist referral
motivated and prior approval is obtained, as clinically essential.
All POLMED beneficiaries need to be referred by a general practitioner to a specialist. The Scheme will impose a co-
Medicine prescribed during hospitalisation forms part of
payment of up to R500 if the specialist does not reflect the
hospital benefits. Medicine prescribed during hospitalisation
referring general practitioner's name on his/her account. The
to be taken out (TTO) will be paid to a maximum of seven days'
co-payment will be payable by the member to the specialist and
is not refundable by the Scheme.
Maternity: The costs incurred in respect of the newborn baby
This co-payment is not applicable to the following specialities/
shall be regarded as part of the mother's cost for the first 90
disciplines: gynaecologists, psychiatrists, oncologists (cancer),
days after birth. If the child is registered on the Scheme within
ophthalmologists, nephrologists (dialysis) and dental specialists.
90 days from birth, Scheme Rule 7.1.2 shall apply.
The Scheme will allow two specialists' visits per beneficiary per
Benefits shall also be granted if the child is stillborn.
year – that do not require general practitioner referral – to cater for those who clinically require annual and/or bi-annual specialist visits.
Specialised radiology
Pre-authorisation is required for all scans. In the case of an emergency the Scheme must be notified within 24 hours or
Ex gratia benefit
on the first working day following the admission or start of
The Scheme may, at the discretion of the Board of Trustees,
treatment, failing which the Scheme will impose a co-payment
grant an ex gratia payment upon written application from
of R500 per procedure.
members, as per the rules of the Scheme.
Pro rata benefits
Prescribed minimum benefits (PMBs) for chronic medication
The maximum annual benefits that are referred to in this
shall be subject to registration on the Disease Risk Management
schedule shall be calculated from 1 January to 31 December
Programme for those conditions that are managed, as well as
each year, based on the services rendered during that year and
chronic medication rules.
shall be subject to pro rata apportionment calculated from the admission date of the member to the Scheme to the end of that
Payment will be restricted to one month's supply in all cases
financial year.
for acute and chronic medicine, except where the member can submit proof that more than one month's supply is necessary due to travel arrangements to foreign countries. (Travel
Designated service provider (out-of-network
documents must be submitted as proof.)
Payment of medicine will be limited to the POLMED Maximum
A designated service provider (DSP) is a healthcare provider
Allowed Cost on both the acute and the chronic benefit
(or group of providers) selected by the Scheme as preferred
categories, where the item is listed on the chronic diseases list.
providers for the diagnosis, treatment and care in respect of one
The balance needs to be funded by the member.
or more prescribed minimum benefit conditions.

DEFINITION OF TERMS
Where the Scheme has appointed a DSP and the member
chooses to use an alternative provider, all costs in excess of
A co-payment is an amount or portion of the cost of a
those agreed with the DSP (including a co-payment), will be for
product or service, which is due by the member to the
the cost of the member and paid directly to the provider by the
provider at the point of service, e.g. consultations or
admission to hospital. The co-payment is not required in the event of a life threatening injury or prescribed
Examples of DSPs (where applicable) are:
minimum condition.
E General Practitioner Network
E Optometrist Network (Visual)
E Renal (Kidney) Network
POLMED Maximum Allowed Cost equivalent
E Cancer (Oncology) Network
E Hospital Network.
The Metropolitan Health Reference Price (MetRef) is
You can access the list of providers on the POLMED website.
the reference pricing system applied by the Scheme's managed healthcare provider. This pricing system refers to the maximum price that POLMED will pay for a
Designated GP Provider (Network GP)
particular medication. Should a reference price be set for a medication, patients are entitled to make use of any
Members are allowed two visits to a non-Network GP, i.e. a GP
medication within this pricing limit, but will be required
who is not part of the network, for emergency or out-of-town
to make a co-payment on medication priced above the
pricing limit.
Designated Pharmacy Network
Specialised dentistry
POLMED has appointed service providers for the provision of
Specialised dentistry refers to services that are not defined
chronic medication.
as basic dentistry. These include periodontal surgery, crowns and bridges, implant procedures, inlays/onlays,
The Scheme utilises the courier pharmacy service as the primary
indirect veneers, orthodontic treatment, removal of
service provider, with the retail pharmacy providing secondary
impacted teeth and maxillo-facial surgery.
support for those members who prefer personal interaction.Where the member chooses to use an alternative provider, the member shall be liable for a co-payment of 20% of the costs paid directly to the provider by the member.
You can access the list of providers on the POLMED website.

STATUTORY PRESCRIBED MINIMUM BENEFITS (PMBs)POLMED LOWER PLANEXPLANATION AND EXAMPLESStatutory prescribed minimum benefits
100% of POLMED rate; or at According to legislation, treatment for these conditions must
cost subject to motivation
be funded by POLMED
PMBs are minimum benefits that by law must be provided to all medical scheme members and include the provision of diagnosis, treatment and care costs for:• any emergency medical condition• a range of conditions, as specified in Annexure A of the
OVERALL OUT-OF-HOSPITAL BENEFITS POLMED LOWER PLANEXPLANATION AND EXAMPLESOVERALL OUT-OF-HOSPITAL BENEFITS
M0: R6 000 (principal
This is the total amount allocated for any healthcare services
received out of hospital, e.g. blood tests, doctor's visits and
Benefits shall not exceed the amount set out in
M1: R7 400 (principal
member and 1 dependant)
This amount is the maximum allocated per member or family
PMBs shall accrue towards the total benefit
M2: R9 000 (principal
– see example below
PMBs are not subject to limits
M3: R9 600 (principal
If you (or a beneficiary) consult a doctor, the account will be paid
In appropriate cases the limit for medical
from the total amount allocated to the out-of-hospital benefit
appliances shall not accrue towards this limit
M4+: R11 000 (principal
Out-of-hospital benefit (M4+):
Consultation: R230
Out-of-hospital balance for the year: R10 770The amount is allocated for the year per member or family and is pro rated depending on the member's joining date
100% of POLMED rate
A R500 co-payment will be payable by the member if not
Subject to referral by a general practitioner (GP)
Referral to Network GP
POLMED will allow 2 specialist visits per
Claims will be paid if referred by a GP
beneficiary per year without a referral
Limited to 4 visits per
Registration on the Disease Risk Management (DRM)
Referral is not necessary for gynaecologists,
beneficiary and 8 visits per
Programme may provide additional PMBs
psychiatrists, oncologists (cancer),
ophthalmologists, nephrologists (dialysis) and
If registered on the DRM Programme for a chronic condition,
dental specialists
a care plan will indicate the number of consultations that are allowed, which will not affect these visits – the treating doctor must use the codes that are on the care plan to ensure payment from the correct benefit
The care plan will indicate from which benefit the consultation will be paid
POLMED LOWER PLANEXPLANATION AND EXAMPLESGeneral practitioner (GP) consultations
POLMED GP Network
Consultations are paid from the out-of-hospital benefit amount
Subject to a maximum number of visits/
Even if funds are left in the out-of-hospital benefit, the
consultations per family per
maximum number of consultations may not be exceeded
annum, as follows:M0: 8 consultations
The GP/specialist must have a copy of the care plan, which
(principal member)
will reflect the codes that must be used when submitting
M1: 12 consultations
a claim for a consultation that relates to a PMB chronic
(principal member/
M2: 15 consultations
(principal member/
Principal member:
8 consultations per year
Principal member:
7 consultations used
M3: 18 consultations
Principal member:
1 consultation left
Out-of-hospital benefit used: R11 000 (M4+)
M4+: 22 consultations
Principal member:
1 consultation required
NO FUNDS AVAILABLE IN OUT-OF-HOSPITAL BENEFIT – CONSULTATION WILL THEREFORE NOT BE PAID BY POLMED DESPITE ONLY 7 CONSULTATIONS USEDNB:If a member chooses to consult a non-network GP he/she will be liable for a co-payment, which will be payable by the member to the GPMedication – acute
100% of POLMED rate
The amount is only available if funds are available in the out-
Subject to available funds in the overall out-of-
of-hospital benefit
Subject to MetRef formulary
The R6 600 is not an extra amount that is added to the out-
R6 600 per family
of-hospital benefit
R11 000 per family cannot be exceeded, even if there are funds available in the out-of-hospital benefit – see example belowExample:Out-of-hospital benefit (M4+):
Acute medication utilised:
Out-of-hospital balance for the year: R4 400
The out-of-hospital balance of R4 400 that is left cannot be used for medication if the full amount of R6 600 per family for medication has been used
Medication – over-the-counter (OTC)
100% of POLMED rate
POLMED allows medication for which you do not require a prescription, i.e. self-medication
Subject to restricted formulary
This is not an additional amount for medication
Maximum of R540 per family The amount can be used for OTC medication if the R6 600
per family for acute medication has not been exhausted
Shared limit with acute medication
POLMED LOWER PLANEXPLANATION AND EXAMPLESMedication – chronic
100% of POLMED rate at
Chronic medication is medication for a condition that
Subject to completion of the relevant chronic
requires ongoing treatment
medication application form and approval
Subject to MetRef formulary The prescription must be sent to POLMED for authorisation
for approved PMB-CDL
before the medication can be obtained from a DSP pharmacy
Medipost Courier Pharmacy
Authorisation may take a few days, unlike acute medication that will be available on the same day
Only medication for chronic conditions that appear on the
list of conditions will be paid
The member must be registered on the Disease Risk Management (DRM) Programme – the application form must be completed by both the member and his/her doctor and returned to POLMED
Medication must be obtained from a DSP pharmacy to avoid or reduce any co-payment that must be made by you
Where a generic medication is available and the member chooses to use the more expensive, original or brand-name medication, he/she must pay the difference in price to the pharmacy
Allied health services
Includes chiropractors, dieticians, homeopaths, chiropody/podiatrists, phytotherapists, reflexologists, naturopaths, orthoptists, osteopaths and therapeutic massage therapists
Benefit based on evidence-based medicine
100% of POLMED rate
You must have funds available in the out-of-hospital benefit
Subject to overall out-of-hospital limit
to access this benefit – refer to the dental benefits further on in this benefit schedule
100% of POLMED rate
Consultations and medication will be paid from the out-of-hospital amount if member is not registered on the
Subject to overall out-of-
Psychiatry Management Programme for depression, PTSD,
bipolar mood disorder and substance abuse
Stand-alone benefit
New additional visits:
Doctor must complete a form to enrol a member/beneficiary
4 post-trauma briefing
sessions with a psychologist or social worker
If registered on the programme, the care plan will indicate the services (consultations and medication) that will be
Subject to referral process
and treatment protocol
All information is treated as confidential
Example if not registered on the programme:Out-of-hospital benefit:
Consultation: R800Medication:
Balance in out-of-hospital benefit: R8 700
Example if registered on the programme:Out-of-hospital benefit:
In-hospital benefit:
Limited to 21 days per
beneficiary per year
Consultation on care plan:
Paid from in-hospital
limitMedication authorised:
Paid from chronic
Balance in out-of-hospital benefit: R11 000
POLMED LOWER PLANEXPLANATION AND EXAMPLES
100% of POLMED rate
Will be paid if referred by a Network GP or specialist
Subject to referral by GP or
Funds must be available in out-of-hospital benefit to access
Maximum of R3 000 per
The R3 000/R7 000 is not an extra amount that is added to
beneficiary and R7 000 per
the out-of-hospital benefit
Members may not go directly to the pathology lab for testing unless referred by a treating doctor
100% of POLMED rate
Will be paid if referred by a GP or specialist
Subject to referral by a Network GP or specialist
Annual limit of R1 650 per
Funds must be available in out-of-hospital limit to access this
Subject to overall out-of-hospital limit
The R1 650 is not an extra amount that is added to the out-of-hospital benefit
100% of POLMED rate
Funds must be available in out-of-hospital limit to access this benefit
Annual limit of R1 650 per family
The R1 650 is not an extra amount that is added to the out-of-hospital benefit
Subject to overall out-of-hospital limit
100% of POLMED rate
Will be paid if referred by a GP or specialist
(E.g. X-rays and ultrasounds)
Annual limit of R2 640 per
Funds must be available in out-of-hospital limit to access this
Subject to referral by a GP or specialist
Ultrasound scans per pregnancy
Limited to three 2D scans
The R2 640 is not an extra amount that is added to the out-
of-hospital benefit
100% of POLMED rate
This scan will only be covered if pre-authorisation was
(E.g. MRI and CT scans)
obtained – irrespective of whether the funds are from the
2 scans per beneficiary per
out-of-hospital or in-hospital benefit
Subject to pre-authorisation
year combined with in-hospital limit
The following information will be needed to obtain authorisation:• radiologist's practice number• treating doctor's practice number• diagnosis code, to indicate the reason for the scan• tariff code• service date
The benefit per beneficiary
PPN is an optometry provider appointed by POLMED to
Includes frames, lenses and eye examinations
(per 24-month benefit cycle)
provide optical services to members
1 eye examination per beneficiary every 2 years
The optometrist will charge the fee that has been agreed to
(unless previously approved for clinical indication) PPN provider would be:
One composite consultation,
Benefits not pro rated
inclusive of a refraction,
Failure to use the DSP will result in an out-of-pocket payment
tonometry and visual field
Each claim for lenses/frames must be submitted screening
If the amount allocated for the frame/test/contact lenses
with a lens prescription
is exceeded, the member will be liable for payment of the
difference directly to the optometrist
Benefits shall not be granted for contact lenses if the beneficiary has already received a pair of
A PPN frame to the value of
spectacles in a 2-year period
R150 or R350 towards the cost of any alternative frame
Annual contact lens limit specified
and/or lens enhancements and either 1 pair of clear
PPN is the Preferred Provider Network
Aquity single vision or clear Aquity bifocal lenses (cost of clear Aquity multi-focal lenses limited to cost of bifocal lenses)
POLMED LOWER PLANEXPLANATION AND EXAMPLES
Contact lenses to the value of R500
Non-PPN provider would be:1 consultation, limited to a maximum cost of R250
R350 frame and/or lens enhancement benefit and one pair of single vision lenses limited to R130 per lens or one pair of clear flat-top bifocal lenses limited to R290
Contact lenses to the value of R500
Subject to clinical protocols
Occupational and speech therapy/
Higher Plan offers extended benefits
Appliances (medical and surgical)
100% of POLMED rate and
Application with quotation must be sent to POLMED to
Oxygen subject to pre-authorisation
authorise the appliance before it is issued
Cost for maintenance is a Scheme exclusion
This is the maximum amount that will be paid for a specific
or R15 600 per set per
Any repairs/maintenance to the appliance will not be paid by
POLMED will unfortunately not replace the device if it is lost
family once every 4 years
A motivation letter from a service provider will be required
for a motorised wheelchair
family once every 4 years
once every 3 years
beneficiary once every 3 years
POLMED LOWER PLANEXPLANATION AND EXAMPLESAppliances (medical and surgical)
catheters and accessories, stoma bags and accessories
transfusion out of hospital
Early detection screening
The correct codes must be used by the doctor to ensure the
Risk assessment tests (refer to schedule F):
limited to periods specified
doctor's consultation for an annual medical examination is
• annual medical examination (code 0190-0192)
not deducted from the number of consultations allowed per
• child immunisation
member/family, as indicated in the out-of-hospital limit
• cholesterol test• bone densitometry scan (DEXA scan)
Members are responsible for informing the doctor that they
• cervical cancer screening
want an annual medical examination and request him/her to
• breast cancer screening
use the correct code
• prostate screening • glaucoma screening
The tests will be paid from the in-hospital benefit and will
• glucose screening
not be deducted from the out-of-hospital limit
• flu vaccine • pneumococcal vaccine
Correct codes must be used by the doctor to ensure
• HIV test and counselling
payment of the account
• dental• hypothyroidism screening• oral contraceptives• hibtiter test
Maternity – home birth
100% of POLMED rate
You need to inform POLMED of your intention to give birth
Subject to pre-authorisation
Limited to R10 000 per beneficiary per annum
You need to ensure that the midwife is fully trained and registered with a valid practice number to render this service
Benefits relating to more
than 2 antenatal ultrasound scans and amniocenteses
You need to obtain authorisation from POLMED to ensure
(amniotic fluid tests) after
the service rendered by the midwife will be paid
32 weeks of pregnancy, are subject to pre-authorisation
100% of POLMED rate
This valuable but confidential service is available to all
Subject to registration on the HIV Management
members and beneficiaries
Case managed in accordance with treatment protocols
IN-HOSPITAL BENEFITS POLMED LOWER PLANEXPLANATION AND EXAMPLES
Pre-authorisation is always required before being admitted to a hospital – phone POLMED for the authorisation number
There is a penalty of R1 000 if no pre-authorisation is obtained for hospitalisation
Note:In the case of an emergency, please obtain pre-authorisation within 48 hours or on the first working day after admission to hospital
When you phone for pre-authorisation, POLMED will require the following:• your membership number• date of birth of patient• practice number of the admitting/treating doctor• practice number of hospital admitted to• ICD-10 code – diagnosis code• procedure code• admission date
Prescribed minimum benefits (PMBs)
100% of POLMED rate at DSP; or at cost, subject to motivation when necessary
Hospital procedures (co-payments)
No co-payment if the
Procedure as per Annexure D
procedure is performed in a DSP hospital and/or day clinic
Annual overall hospital limit
100% of POLMED rate
Subject to pre-authorisation
Unlimited in DSP hospitals
Non-PMB day admissions (excludes to-take-out (TTO) medication)
R8 000 co-payment in non-DSP hospitals
Unlimited for emergency and PMB conditions
Not allowed in hospital
Subject to dental protocols
Not allowed in hospital
Subject to dental protocols
Emergency medical assistance
100% of POLMED rate
Netcare 911 on 082 911
100% of POLMED rate
Pre-authorisation required for admission
Subject to registration on the HIV Management Programme
Case managed according to Member must be registered on the HIV Management treatment protocols
The hospital must contact POLMED if the authorised length of stay is not sufficient
Chronic kidney dialysis
100% of POLMED rate at
Pre-authorisation for dialysis in hospital must be obtained
Subject to PMBs, pre-authorisation and
registration on the Disease Risk Management
Member must be registered on the DRM Programme and
Subject to managed
Chronic Medicine Management Programme for ongoing
healthcare protocols
National Renal Care (NRC) and Fresenius Medical Care are preferred providers
POLMED LOWER PLANEXPLANATION AND EXAMPLESMaternity benefits (also see maternity –
100% of POLMED rate
Pre-authorisation must be obtained in advance
home birth)Subject to pre-authorisation and registration on
The member must be registered on the Maternity
the Maternity Management Programme
Management Programme
The POLMED Membership Department must be informed of the birth of the baby to facilitate its registration as a dependant
Note that third generation babies (grandchildren) do not qualify for membership and their treatment in hospital will not be covered
Not allowed in hospital
Subject to pre-authorisation
100% of POLMED rate
The treating doctor will be required to send a DSMIV form to
Subject to PMBs, pre-authorisation and
the psychiatric case manager
registration on the Psychiatry Management
Only PMBs and post-
Programme for the following conditions:
traumatic stress disorder
• depression• bipolar mood disorder
Annual limit of 21 days per
• substance abuse
• post-traumatic stress disorder (PTSD)
100% of POLMED rate at
Non-PMB specialist drug limit (e.g. biologics)
Subject to pre-authorisation
Specialised medicine sub-limit of R54 000 per family
Oncology (chemotherapy and
100% of POLMED rate at
After a diagnosis of cancer is made, the treating doctor will
radiotherapy) – cancer
be required to submit a treatment plan to the Oncology
Subject to pre-authorisation and registration on
Management Programme
the Oncology Management Programme
Limited to R180 000 per beneficiary
The oncology case manager will issue authorisations for both
Independent Clinical Oncology Network (ICON)
consultations and investigations for a period
MRI/CT scans will be funded from the oncology benefit
Organ and tissue transplants
100% of POLMED rate
A letter of motivation and quotations from the treating
Subject to pre-authorisation and clinical
doctor will be required
guidelines used in State facilities
No benefit except for PMBs
Unlimited radiology and pathology for organ transplants and immunosuppressants
100% of POLMED rate
Blood tests done in hospital when the patient was admitted
Subject to protocols and clinical guidelines
will be paid from the in-hospital benefit
100% of POLMED rate
The admitting diagnosis should be related to the reason for
Subject to pre-authorisation
physiotherapy, e.g. back pain
Prosthesis (internal and external)
100% of POLMED rate
When planning an operation, a quotation needs to be
Subject to pre-authorisation and approved
approved before the operation
Limited to R54 000 per beneficiary
Examples of internal prosthesis:• knee and hip replacements• stents (used for heart operations)• meshes (used in hernia repairs)
Example of external prosthesis:• artificial limbs

POLMED LOWER PLANEXPLANATION AND EXAMPLES
100% of POLMED rate
The following information will be needed to obtain
Subject to pre-authorisation
Limited to R27 500 per family • radiologist's practice number
• treating doctor's practice number
Subject to a limit of 2 scans
• diagnosis code to indicate reason for the scan
per annum per beneficiary,
including scans out of
100% of POLMED rate
An example of a basic radiology test is a chest X-ray
100% of POLMED rate
150% of POLMED rate
Members should confirm the anaesthetist's tariffs before the operation
Where anaesthetists charge private rates that are above POLMED rates, the member will be liable for the difference
ANNEXURE B2CO-PAYMENTSThe elective procedures stipulated under Annexure D for the Lower Plan can only be performed in a DSP hospital and/or day clinic; otherwise the following co-payments will be applicable:
Allows for 2 out-of-network visits
Joint replacement
Laparoscopic nissen
Hospital DSP (where applicable)
PHARMACY OUT-OF-NETWORk RULE
Where the Scheme has appointed a DSP and the member
Endoscopy, e.g. gastroscopy
chooses to use an alternative provider, the member will be
liable for a co-payment of 20% of costs, which he/she must
pay directly to the provider.ANNEXURE B4
LOWER PLAN CHRONIC CONDITIONS LISTLIST OF CHRONIC CONDITIONS: SUBjECT TO PMBs(SUBJECT TO THE PROVISIONS IN THE ACT AND REGULATIONS IN RESPECT OF PMBs).
Coronary artery disease
Rheumatoid arthritis
Cardiac dysrythmias
Parkinson's diseaseMultiple sclerosis
Chronic obstructive pulmonary disease
Affective disorders (depression and
bipolar mood disorders)
Schizophrenic disorders
Ulcerative colitis
Chronic renal failure
Diabetes mellitus type IDiabetes mellitus type II
SPECIAL CATEGORY CONDITIONS
Diabetes insipidus
AUTO-IMMUNE DISORDERSSystemic lupus erythematosis (SLE)ANNEXURE EPOLMED DENTAL BENEFIT TABLE 2012 – LOWER PLANDental benefits are paid at 100% of the prescribed tariff. The dental protocols and benefit rules apply to all options. All specialised dentistry and hospitalisation must be authorised.
Routine consultations, cleaning of teeth and fluoride application Twice annually per beneficiary
Oral hygiene instructions
Once in 12 months per beneficiary
Permanent molars up to 21 years
X-rays (radiographs)
Extra-oral radiography limited to a 2-year period
Once per tooth within 12 months, with a maximum of 4 fillings per
beneficiary per annum
If more than 4 fillings are required, your dentist should submit a dental plan for the beneficiary to POLMED
Maximum of 2 per beneficiary per annum
DENTISTR
Root canal treatment
If more than 2 are required, your dentist should submit a dental plan for the beneficiary to POLMED
Surgical removal of teeth, including impacted teeth
Pre-authorisation required if done in hospital (for impacted teeth only)
All identified beneficiaries to be registered on the Periodontal Programme
Root planning (non-surgical periodontal interventions)
As per clinical protocolsOver the age of 12 years
Once every 24 months
All the above are subject to overall out-of-hospital limit
Periodontal surgery
No specialised dentistry other than for PMBs
Metal base to partial denture
No specialised dentistry other than for PMBs
Crown and bridge work
No specialised dentistry other than for PMBs
Orthodontic treatment
No specialised dentistry other than for PMBs
Maxillo-facial surgeryThese procedures are paid for from the major risk benefit
No specialised dentistry other than PMBs
They are subject to pre-authorisation, unless it is an emergency
In all cases pre-authorisation is required, failing which the Scheme will impose a co-payment of R500
Written motivation and radiographs
Children under the age of 7 years
Subject to Scheme's approval
Written motivation and radiographs
Surgical removal of teeth
Subject to Scheme's approvalOnly for surgical removal of multiple impacted teeth
No benefit in hospital
Periodontal surgery
No benefit in hospital
Written motivation and radiographs
Surgical exposures of unerupted canines
Subject to Scheme's approval
Written motivation and radiographs
Allergic to local anaesthetic
Subject to Scheme's approval
Written motivation and radiographs
Oro-facial and dental trauma
Subject to Scheme's approval
Patients with either physical, mental or medically
Written motivation and radiographs
compromising conditions
Subject to Scheme's approval
Orthognathic surgery
No specialised dentistry other than for PMBs
ANNEXURE B3SCHEDULE OF CONTRIBUTIONSThe monthly contributions below are payable by or on behalf of the member, per registered beneficiary.
The contributions for 2012 are set out below in the format required by the Registrar in circular 19.
CONTRIBUTION RATES LOWER PLAN 2012 (until 31 March 2012)
TOTAL CONTRIBUTION (ExCLUDING EMPLOYER SUBSIDY)
MEMBER CONTRIBUTION (SUBSIDISED CONTRIBUTION)
R4 051 – R5 650
R4 051 – R5 650
R5 651 – R7 000
R5 651 – R7 000
R7 001 – R8 200
R7 001 – R8 200
R8 201 – R9 650
R8 201 – R9 650
R9 651 – R11 700
R9 651 – R11 700
R11 701 – R14 500
R11 701 – R14 500
R14 501 – R18 500
R14 501 – R18 500
R18 501 – R20 800
R18 501 – R20 800
PLEASE NOTE: Where parents have been registered as dependants, the full contributions (without subsidy) will be payable.For example, R1 069 (father) + R1 069 (mother) + R471 (member) + R471 (spouse) = R3 080 per month.CONTRIBUTION RATES LOWER PLAN 2012 (with effect from 1 April 2012)
TOTAL CONTRIBUTION (ExCLUDING EMPLOYER SUBSIDY)
MEMBER CONTRIBUTION (SUBSIDISED CONTRIBUTION)
R4 501 – R6 150
R4 501 – R6 150
R6 151 – R7 500
R6 151 – R7 500
R7 501 – R8 700
R7 501 – R8 700
R8 701 – R10 200
R8 701 – R10 200
R10 201 – R12 400
R10 201 – R12 400
R12 401 – R15 300
R12 401 – R15 300
R15 301 – R19 300
R15 301 – R19 300
R19 301 – R21 700
R19 301 – R21 700
PLEASE NOTE: Where parents have been registered as dependants, the full contributions (without subsidy) will be payable.For example, R1 144 (father) + R1 144 (mother) + R481 (member) + R481 (spouse) = R3 250 per month.ANNEXURE C – APPLICABLE TO BOTH HIGHER PLAN AND LOWER PLANGENERAL EXCLUSIONSThe following services/items are excluded from benefits with due regard to prescribed minimum benefits (PMBs) and will not be paid by the Scheme:
1. Services not mentioned in the
10. Aids for participation in sport, e.g.
28. Unless otherwise indicated by the
benefits, as well as services which, in
Board, costs for services rendered
the opinion of the Scheme, are not
11. Gold inlays in dentures and crown
by any institution, not registered in
aimed at the treatment of an actual
work and bleaching of vital (living)
terms of any law;
or supposed illness or disablement
29. All costs in respect of sickness
that impairs or threatens essential
conditions that were specifically
body functions (the process of
12. Subject to the benefits in Annexure
excluded from benefits when the
ageing will not be regarded as an
A and B, the treatment of dental
member was admitted to the
illness or a disablement);
Scheme for 12 months from the date
2. Sleep therapy;
13. Any orthopaedic and medical aids
not mentioned in Annexure A and B;
3. Reversal of sterilisation procedures,
30. Unless otherwise decided by
provided that the Board may decide
14. Reports, investigations or tests for
the Board, benefits in respect
to grant benefits in exceptional
insurance purposes, admission to
of medicines obtained on a
universities or schools, fitness tests
prescription are limited to one
and examinations, medical court
4. The artificial insemination of a
month's supply for every such
reports, employment, emigration or
person in or outside the human
prescription or repeat thereof;
immigration, etc.;
body, as defined in the Human
31. Any health benefit not included
Tissue Act, 1983 (Act 65 of 1983),
15. Sex change operations;
in the list of prescribed benefits
provided that, in the case of
16. Bandages and plasters, unless
(including newly-developed
artificial insemination, the Scheme's
prescribed after an operation or
interventions or technologies) will
responsibility on the treatment will
be excluded from benefits until and
unless the benefits are revised to
• limited to the hospital-based
17. Travelling costs except services
(medical and surgical) diagnostic
according to the benefits in
32. Compensation for pain and
and treatment practice
Annexure A and B;
suffering, loss of income, funeral
• as it is prescribed in a public
18. Accounts of persons not registered
expenses or claims for damages;
with a recognised professional body
• as defined in the PMBs
constituted in terms of an Act of
33. Nappies excluded and benefits
• subject to pre-authorisation and
for adult use will only be granted if
prior approval by the Scheme
authorised prior with motivation;
19. Accommodation in spas or health or
5. Charges for appointments that a
34. Benefits for organ transplant donors
member or dependant failed to
to recipients who are not members
keep with service providers;
20. Holidays for recuperative purposes;
6. Prenatal and/or post-natal exercises;
21. The treatment of obesity, provided
35. Benefits for medical expenses
that with prior motivation the
sustained as a result of injuries on
7. Operations, treatments and
Scheme may approve benefits for
procedures, by choice, for cosmetic
the treatment of morbid obesity;
purposes, where no pathological
36. Claims relating to the following:
substance exists that proves the
22. Muscular fatigue tests, except if
• aptitude tests
necessity of the procedure, and/
requested by a specialist and a
or that is not life-saving, life-
doctor's motivation is enclosed;
• school readiness
sustaining or life-supporting; for
23. Subject to the benefits in Annexure
• questionnaires
example breast reduction, breast
A and B, the treatment of alcoholism
• marriage counselling
augmentation, otoplasty, total
• learning problems
nose reconstruction, lipectomy,
• behavioural problems
24. Any treatment as a result of
subcutaneous mastectomy, minor
surrogate pregnancy;
37. Benefits for tints and photochromic
superficial varicose veins treatment
with sclerotherapy, abdominal bowel
25. Blood pressure appliances,
bypass surgery, etc.;
provided that the Board may decide
38. Cosmetics and sun block;
to grant benefits in exceptional
8. Plastic and reconstructive surgery
39. Appliances and devices, e.g. non-
is excluded from benefits, unless
diabetic syringes.
prior approval by the Scheme is
26. Non-functional prosthesis used for
granted as clinically essential and not
reconstructive/restorative surgery,
provided that the Board may decide to grant the benefits in exceptional
9. Accommodation in an old-age
home or other institution that provides general care for aged and/
27. Benefits for costs of repair,
or chronically ill patients, unless
maintenance, parts or accessories
approved by the Scheme;
for the appliances or prosthesis;
ANNEXURE C – APPLICABLE TO BOTH HIGHER PLAN AND LOWER PLANACUTE MEDICINE EXCLUSIONSThe following categories of medicines are excluded from acute medicine benefits:
Gender/sex related:
Vitamin and/or mineral
Treatment of female
Multivitamins or minerals
Gender/sex related:
Vitamin and/or mineral
Androgens and anabolic
Geriatric vitamins and/or
Slimming preparations
Vitamin and/or mineral
Patent medicines:
Household remedies
Tonics and stimulants
Patent medicines:
Vitamin and/or mineral
Patent and over-the-
Calcium diet supplementation
Patent medicines:
Vitamin and/or mineral supplements:
Patent medicines:
Patent medicines:
Vitamin and/or mineral
Soaps and cleansers
Patent medicines:
Vitamin and/or mineral
Patent medicines:
Contact lens preparations
Unregistered vitamins,
minerals or food
Patent medicines:
Patent sunscreens
Naturo- and homeopathic
Patent medicines:
Medicated shampoo
Homeopathic remedies
Patent medicines:
Naturo- and homeopathic
Veterinary products
Appliances, supplies and
Topical preparations:
Medical appliances/
Appliances, supplies and
Veterinary products
Bandages, dressings,
cotton wool and gauze
Medicines where cost/
Appliances, supplies and
benefit ratio cannot be
Herceptin Gleevac®
Disposable cholesterol
All newly-registered
Nappies, molipants,
Appliances, supplies and
linen savers, except
Incontinence products
Other items and categories that can be excluded according to evidence-based medicine principles, as
Diagnostic agents
approved by the Scheme from time to time.
Other immunoglobulins
ANNEXURE C – APPLICABLE TO BOTH HIGHER PLAN AND LOWER PLAN
The following categories are not available on acute medicine benefits:
Gender/sex related:
Treatment/prevention of
Treatment of impotence/
sexual dysfunction
Alcohol, except PMBs
Appliances, supplies and
Stoma products and
accessories, except
Erythropoietin, except
where it forms part of
PMB-related services
Appliances, supplies and
Haemostatics, except
Medicated dressings,
except where these form
part of PMB-related
regulators and oxygen
Appliances, supplies and
Surgical appliances/
products for home
Treatment/prevention of
ANNEXURE D – APPLICABLE TO BOTH HIGHER PLAN AND LOWER PLANPROCEDURES PRE-AUTHORISED UNDER AUSPICES OF MANAGED HEALTHCARE IF THESE PROCEDURES ARE PERFORMED IN THE PRE-AUTHORISATION POLICIES AND PROCEDURESDOCTORS' ROOMS THERE IS NO NEED FOR PRE-AUTHORISATION.
Where applicable, pre-authorisation must be obtained for clinical services and will be subject to benefit limits. Within the
• Any minor surgical procedure, e.g. lymph node biopsy
auspices of managed healthcare, a clinical motivation might be
• Breast biopsy
• Cauterisation of warts• Circumcision• Cone biopsy
PRE-AUTHORISATION FOR HOSPITALISATION
• Drainage of small abscesses• Endoscopy of the nose
All hospital admissions must be pre-authorised (where
• Excision of superficial benign tumours
indicated, a hospital network will apply).
• Fine needle biopsy
• You may obtain a hospital authorisation number by phoning
• Ganglion excision
the Hospital Risk Management Programme on 0860 104 111
• Payment to a hospital is subject to pre-authorisation,
• Intra-articular hydrocortisone injection
clinical necessity, appropriate treatment, benefit limits and
• Laser procedures
prescribed minimum benefits (PMBs).
• If you are admitted to an intensive care unit or high care
• Nasal plugging for epistaxis
ward, the hospital is required to motivate your continued
• Nasal cautery
accommodation in either of these facilities every 72 hours.
• You may be liable for a co-payment if your option stipulates
• Removal of small hardware
that you use a hospital network (except in an emergency),
• Superficial foreign body removal
and/or have not obtained pre-authorisation.
• Skin biopsy (subject to confirmatory histology results) – out-
• In case of an emergency the Scheme must be notified within
of-hospital benefit
48 hours or the first working day after treatment/admission.
An authorisation does not guarantee payment.THE FOLLOWING ELECTIVE PROCEDURES WILL BE FUNDED FROM IN-HOSPITAL BENEFITS IF PERFORMED IN DOCTORS' ROOMS OR DAY CLINICS. IF THESE ARE PRE-AUTHORISATION FOR DENTISTRYPERFORMED IN HOSPITAL, THE MEMBER WILL BE LIABLE FOR A CO-PAYMENT, UNLESS IN THE CASE OF AN
It is not necessary to obtain authorisation for routine
EMERGENCY. IF THESE PROCEDURES ARE PERFORMED
procedures, e.g. fillings and extractions.IN THE DOCTORS' ROOMS, THERE IS NO NEED FOR PRE-AUTHORISATION.Basic dentistry• The Scheme must authorise dental procedures that require
• Arthroscopy – knee, shoulder
• Procedures performed under general anaesthesia are only
• Circumcision (children who are younger than 10 years)
permitted for children under the age of seven years or in case
of the surgical removal of impacted wisdom teeth.
• Colposcopy• D&C/evacuation
• Endoscopy of the nose
• All specialised dentistry services and procedures must be
• Functional endoscopic sinus surgery
• If any of the procedures involve hospitalisation, the member
must obtain a pre-authorisation number via the Hospital Risk
• Laparoscopy – diagnostic, sterilisation
• Lithotripsy• Local excision of lump in breast (lumpectomy)• Meibomian cysts excision
PRE-AUTHORISATION FOR PMB CHRONIC DISEASE LIST
• Minor perianal surgery
• Myringotomy• Nasal cautery
• The Disease Risk Management Programme's care plan
• Nasal polypectomy
will allow each registered beneficiary a certain number
of consultations and investigations annually according to
• Sigmoidoscopy
• The beneficiary is notified about these benefits at the
• Squint repair/strabismus
beginning of each calendar year or shortly after being
diagnosed with the condition.
• Thyroid cyst/nodule biopsy
• No co-payment applies for the treatment of a PMB-CDL
condition if you use the medicines in the MetRef formulary.ANNEXURE F – APPLICABLE TO BOTH HIGHER PLAN AND LOWER PLANPOLMED PREVENTATIVE HEALTHCARE BENEFITS 2012POLMED has outlined services covered under preventative healthcare benefits. Best clinical practice dictates that the doctor should follow best clinical management, as per the guidelines, even when it is not specified under this benefit.
All services specified in this schedule are to be covered from the in-hospital benefit.TARIFF CODESTARIFF CODESFull annual medical Osteoporosis screening (DEXA scan, excluding sonar):
• Consultation;
0190-0192 (use in-
Women over 65 years, once in a
house code 5550 for
submission of claims)
See www.polmed.co.za
• Cholesterol screening;
All forms recommended by the
for more information
• Glucose screening; and
National Department of Health
• Healthy diet counselling
Men between 50 and 75 years of 4524
Children under the age of
0022: Administration of
6 years in line with the National
Department of Health schedule
88452: Immunisation at
Well Baby Clinics
• Beneficiaries between 40 and
99203: Preventative care:
64 years of age once every 3
Optometrist: 11202 (refer
Immunisation, e.g. cost
to Preferred Provider
• Beneficiaries that are 65 and
older once every year
Hypothyroidism screening:In newborn babies (younger Flu vaccine:
Flu vaccine for all age groups
Dental:• Consultation, including Hibtiter (specific antibody titer
oral hygiene instruction for
children aged 6 years and
Children age 5 years and
• Oral hygiene instruction for
Members aged 60 years and
members between the ages of
7 and 18 years annually
• Carries risk assessment for
Only high-risk patients such
Nappi: 836699 (Imovax
babies up to children aged
as those who are HIV positive,
14 years once every second
have sickle cell disease (blood
disorder) or splenectomy
• Dental screening, including
periodontal disease; carries risk assessment for
beneficiaries over 19 years of
Test – All age groups (ELISA
age once every second year
and Western blot; however, the
Western blot: 3969
Western blot is only payable
Cervical cancer screening (pap
after the ELISA test results were
Women between 21 and 64
Counselling – All age groups
0016 (pre-counselling
years of age once every three
before and after testing annually
0017 (post counselling –
Exclusion: Women who have had
a complete hysterectomy with no residual (remaining) cervixBreast cancer screening (mammogram):• Women between 40 and 50
years of age once every 2
• Women between 51 and 70
years of age annually

What are prohibited substances ? What samples are collected from the horse ? Most medicines and drugs are prohibited if detected in a If your horse needs veterinary assistance or treatment at Usual y urine and blood are col ected under the direct su- horse at the time of competition. This ruling is based on the an event, your treating/team veterinarian must obtain